Coverage Authorization List

Brand Name	Generic Name	Effective Date	Requirements	Class
Ibrance	Palbociclib	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Oncology
Ibudone	ibuprofen/hydrocodone	03/01/2018	Requires Prior Approval Requires Step Therapy Subject to Quantity Limits	Opioid Analgesics
Iclusig	ponatinib tablets	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Oncology
Idelvion	coagulation factor IX [recombinant], albumin fusion protein	01/01/2017	Requires Excluded Exception Approval	Hemophilia
Idhifa	enasidenib	01/01/2018	Requires Excluded Exception Approval	Oncology
Ilaris	canakinumab for subcutaneous [SC] injection	01/01/2017	Requires Prior Approval	Cryopyrin Associated Periodic Synd (CAPS)
Ilumya	tildrakizumab-asmn	01/01/2019	Requires Prior Approval	Autoimmune
Imbruvica	Ibrutinib	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Oncology
Imfinzi	durvalumab	01/01/2018	Requires Excluded Exception Approval	Oncology
Imitrex	sumatriptan tablets	01/01/2017	Requires Prior Approval Subject to Quantity Limits	Antimigraine
Imlygic	Talimogene Laherparepvec	01/01/2017	Requires Prior Approval	Oncology
Impoyz (Brand Only)	clobestasol	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Inbrija	levodopa inhalation powder	04/01/2019	Requires Prior Approval Subject to Quantity Limits	Parkinson's Disease
Increlex	mecasermin [rDNA origin] injection	01/01/2017	Requires Prior Approval	Growth Hormone and Related Disorders
Inflectra	infliximab-dyyb	03/20/2020	Requires Excluded Exception Approval	Autoimmune
Ingrezza	valbenazine	01/01/2018	Requires Excluded Exception Approval	Tardive Dyskinesia
Inlyta	Axitinib	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Oncology
Inova	benzoyl peroxide/salicylic acid pad	09/01/2017	Requires Prior Approval Requires Step Therapy	Topical Acne Products
Inrebic	fedratinib	10/01/2019	Requires Prior Approval	Oncology
Intelence	etravirine	01/01/2018	Subject to Quantity Limits	HIV
Intermezzo	zolpidem	01/01/2018	Requires Excluded Exception Approval	Sedative-Hypnotics
Intron A	Interferon Alfa-2b	01/01/2017	Requires Prior Approval	Oncology
Invirase	saquinavir	01/01/2018	Subject to Quantity Limits	HIV
Invokamet	canagliflozin/metformin	01/01/2018	Requires Excluded Exception Approval	Diabetes
Invokana	canagliflozin	01/01/2018	Requires Excluded Exception Approval	Diabetes
Iressa	Gefitinib	01/01/2017	Requires Prior Approval	Oncology
Isentress	raltegravir	01/01/2018	Subject to Quantity Limits	HIV
Istodax	Romidepsin	01/01/2017	Requires Prior Approval	Oncology
Ixempra	Ixabepilone	01/01/2017	Requires Prior Approval	Oncology
Ixinity	Factor IX Concentrates	01/01/2017	Requires Prior Approval	Hemophilia
Jadenu	deferasirox	01/01/2017	Requires Prior Approval	Iron Overload
Jakafi	Ruxolitinib	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Oncology
Jatenzo	testosterone undecanoate oral	01/01/2018	Requires Excluded Exception Approval	Testosterone Products
Jevtana	Cabazitaxel	01/01/2017	Requires Prior Approval	Oncology
Jivi	antihemophilic factor (recombinant) PEGylated-auci	01/01/2019	Requires Prior Approval	Hemophilia
Jornay PM	methylphenidate extended-release	01/01/2019	Requires Prior Approval Subject to Quantity Limits	ADHD-Narcolepsy Agents
Jublia	efinaconazole topical solution	01/01/2017	Requires Prior Approval	Topical Antifungals
Juluca	dolutegravir-rilpivirine	01/01/2018	Subject to Quantity Limits	HIV
Juxtapid	lomitapide capsules	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Lipid Disorders
Jynarque	tolvaptan	01/01/2019	Requires Prior Approval	Retinal Disorders
Kadcyla	Ado-Trastuzumab emtansine	01/01/2017	Requires Prior Approval	Oncology
Kadian	morphine sulfate ER capsules	03/01/2017	Requires Prior Approval Requires Step Therapy Subject to Quantity Limits	Opioid Analgesics - Extended-Release
Kalbitor	Ecallantide	01/01/2017	Requires Prior Approval	Hereditary Angioedema
Kaletra	lopinavir/ritonavir	01/01/2018	Subject to Quantity Limits	HIV
Kalydeco	ivacaftor tablets	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Cystic Fibrosis
Kanjinti	trastuzumab-anns	01/01/2017	Requires Prior Approval	Oncology
Kanuma	Sebelipase alfa	01/01/2017	Requires Prior Approval	Lysosomal Storage Disorders
Kenalog (Brand Only)	triamcinolone acetonide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Kerydin	tavaborole topical solution	01/01/2017	Requires Prior Approval	Topical Antifungals
Kesimpta	ofatumumab	10/01/2020	Requires Prior Approval	Multiple Sclerosis